Patients taking second-generation antipsychotics (SGAs) are at increased risk of developing metabolic syndrome because of the side effect profiles of these medications. A medication use evaluation (MUE) was conducted and showed that baseline monitoring rates of metabolic parameters in patients taking SGAs are low. A pharmacist-run metabolic syndrome monitoring clinic (MSMC) is available to mental health (MH) outpatients; however, the clinic is underused by providers. The purpose of this project was to increase baseline metabolic syndrome monitoring rates in patients taking SGAs by implementing interventions to overcome barriers to monitoring and to accessing the MSMC. Appropriate tools to improve monitoring were obtained, and an electronic consult for the MSMC was created. A presentation and pamphlet were developed to improve awareness. Information about free patient transportation was obtained and distributed. Efficacy was assessed by evaluating patient referrals to the clinic before and after intervention, comparing baseline monitoring rates after implementation with the MUE data, and administering an anonymous survey to outpatient MH providers. There was a 37.5% increase in overall referral rates to the MSMC after intervention, but only 51.5% of patients attended appointments as scheduled. Monitoring of vital signs increased, but monitoring of laboratory parameters decreased. A total of 60% (9 of 15) of providers completed a survey, of which one third indicated they still forget to refer patients to the MSMC. Overall, baseline metabolic monitoring rates remained low despite implementing several interventions. Patient and provider outreach is crucial for initiating and maintaining a successful metabolic monitoring system for patients taking SGAs.Abstract
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Despite the theory that long-acting injectable (LAI) antipsychotics should be more likely to improve adherence, reduce gaps in therapy, and prevent relapse compared with oral antipsychotics, there is little published evidence on this issue, specifically in patients with early psychosis. Patients with a new diagnosis for a psychotic disorder between July 1, 2013, and August 31, 2014, were retrospectively evaluated during a 12-month duration. The primary outcomes were adherence and persistence. Adherence was determined by proportion of days with medication, and persistence was defined as zero gaps in medication therapy. The secondary outcome was the number of times a psychiatric acute care service was used. Patients were divided into 3 groups based on their antipsychotic prescription history: oral only, LAI only, or both formulations at separate times throughout the study period. Forty-seven patients met inclusion criteria. The average proportions of days with medication were 32%, 76%, and 75% for the oral, LAI, and both formulations groups, respectively (P < .001). For medication persistence, there were 32 patients (91%), 3 patients (75%), and 5 patients (63%) with at least 1 gap in therapy for the oral, LAI, and both formulations groups, respectively (P = .098). For acute care services, there was a median number of zero acute care visits for each of the 3 groups (P = .179). A post hoc subgroup analysis found medication adherence to be statistically different between the oral and LAI groups. Long-acting injectable antipsychotics were associated with better adherence compared with oral antipsychotics in patients with early psychosis.Abstract
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Clozapine is an atypical antipsychotic medication approved for treatment-resistant schizophrenia and suicidal behavior in schizophrenia or schizoaffective disorders. Despite its therapeutic efficacy, clozapine is associated with several adverse effects, including agranulocytosis. In late 2015, the Food and Drug Administration updated the risk evaluation and mitigation strategy (REMS) for clozapine with new requirements for monitoring, prescribing, and dispensing. The purpose of this study was to evaluate clozapine prescribing practices at a Kentucky state psychiatric hospital before and after the implementation of the updated REMS program. The primary outcome of this study was to evaluate clozapine prescribing practices by identifying the number of patients on clozapine therapy in the 6 months pre and post updated REMS implementation. Included in the study were patients at a Kentucky state psychiatric hospital on clozapine therapy for the 24 months before the updated REMS implementation and in the 6-month study period after the implementation. The secondary objective of this study examined psychiatrist comfort level of prescribing clozapine. Since the implementation of the updated REMS program, there has been an increased percentage of patients that were prescribed clozapine at a Kentucky state psychiatric hospital. This increase was not statistically significant (P = .2610). The prescribing practices of clozapine within this facility did not differ significantly comparing pre- and post-REMS change in terms of number of patients prescribed clozapine, patient's dose, and therapy duration. Data from this study contributes to the body of knowledge evaluating this new standard of practice under the updated REMS.Abstract
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Venous thromboembolism (VTE) prophylaxis is not included among the measures for the Inpatient Psychiatric Facilities Quality Reporting Program. Evidence suggests that antipsychotic agents may be an independent risk factor for the development of VTE; therefore, development of a VTE risk stratification tool would improve the quality and safety of care for the psychiatric inpatient population. This study aims to develop clinically relevant criteria to assess VTE risk upon admission to an inpatient psychiatric hospital. This retrospective, single-center cohort study enrolled patients in 2 cohorts from an inpatient psychiatric hospital. Patients in cohort I with new-onset VTE diagnosis during admission were identified through international classification of diseases 9 and 10 coding. Cohort II consisted of a random sample of 100 patients in a 3-month period. The percentage meeting criteria for prophylaxis in each cohort was assessed utilizing both the Padua Prediction Score and a modified score. In cohorts I and II, 66.7% and 14% of patients, respectively, met criteria for VTE prophylaxis utilizing the modified Padua Prediction Score. One patient received VTE prophylaxis in each cohort, and the median time to VTE diagnosis in cohort I was 42 days. In cohort I, the rate of VTE was 0.08% based on estimated discharges in the 26-month period. This is less than the annual rate of 1% to 2.4% for nursing homes or postacute rehabilitation facilities. We recommend the implementation of clinical decision support to prompt individualized reassessment of VTE risk when length of stay exceeds 30 days.Abstract
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Valproic acid (VPA)–induced hyperammonemia poses several clinical challenges in psychiatric medicine. The reported incidence of this adverse effect varies widely across the literature. Furthermore, practitioners treat hyperammonemia in asymptomatic patients although studies suggest this practice is unnecessary. The purpose of this study is to evaluate if patients with VPA-induced hyperammonemia are appropriately identified for treatment based on their symptom presentation as well as determine the most efficacious treatment approach for VPA-induced hyperammonemia. This study was completed at a community teaching hospital, and patients were retrospectively identified from June 1, 2011, to June 30, 2016, and included if they were admitted to a psychiatric unit, received at least 1 dose of VPA, and had at least 1 ammonia level drawn during admission. Hyperammonemia was defined as greater than 47 μmol/L, and symptomatic hyperammonemia was defined based on specific symptom presentation. The treatment modality was successful if the ammonia level was within normal range at discharge. Of the 357 patients screened, 347 patients met all inclusion criteria for analysis. The reported incidence of hyperammonemia was found to be 36% with 43.2% of those patients presenting with symptoms. Lactulose initiation was the most common treatment modality chosen (48.7%). Discontinuation of VPA was the most effective treatment (56.3% success rate). The results demonstrate that many patients with elevated ammonia levels are asymptomatic and therefore, based on findings within the literature, may not require treatment. Although lactulose was found to be the most common treatment initiated, the most effective was discontinuation of VPA.Abstract
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Smoking cessation is a chronic issue surrounding individuals with schizophrenia. It is estimated that up to 90% of patients diagnosed with schizophrenia smoke cigarettes. The purpose of this article is to provide a nonsystematic review of the efficacy of smoking cessation interventions as well as to explore the potential neuropsychiatric adverse effects of these agents in patients with schizophrenia. Eighteen studies were found and included in the review. Overall, nicotine replacement therapy, bupropion, and varenicline have all proven their effectiveness at either promoting smoking abstinence or a significant reduction in cigarette use.Abstract
The incidence of posttraumatic stress disorder (PTSD) is common within the population and even more so among veterans. Current medication treatment is limited primarily to antidepressants. Such medicines have shown to produce low remission rates and may require 9 patients to be treated for 1 to have a response. Aside from the Veterans Affairs/Department of Defense guidelines, other guidelines do not recommend pharmacotherapy as a first-line option, particularly in the veteran population. Marijuana has been evaluated as an alternative and novel treatment option with 16 states legalizing its use for PTSD. A systematic search was conducted to evaluate the evidence for the use of marijuana for PTSD. Studies for the review were included based on a literature search from Ovid MEDLINE and Google Scholar. Five studies were identified that evaluated the use of marijuana for PTSD. One trial was conducted in Israel and actively used marijuana. Three studies did not use marijuana in the treatment arm but instead evaluated the effects postuse. A retrospective chart review from New Mexico relied on patients to recall their change in PTSD symptoms when using marijuana. Three studies concluded there might be a benefit, but two discouraged its use. Although the two negative studies show a statistical difference in worse PTSD outcomes, clinical significance is unclear. Conflicting data exist for the use of marijuana for PTSD; however, current evidence is limited to anecdotal experiences, case reports, and observational studies, making it difficult to make clinical recommendations.Abstract
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Various publications have noted increases in dopamine, specifically in the mesolimbic region of the brain, to have a direct correlation to psychotic-like symptoms. Venlafaxine, a first-line medication for depression, inhibits the reuptake of both serotonin and norepinephrine. Additionally, venlafaxine weakly inhibits the reuptake of dopamine. Phentermine/topiramate (Qsymia®), specifically the phentermine component, functions by blocking the dopamine and norepinephrine transporter, similar to amphetamine. A 40-year-old Hispanic woman was admitted to the inpatient mental health unit based on reports of delusional thinking and several attempts of self-harm. Past medical history was significant for major depressive disorder, posttraumatic stress disorder, anxiety, irritable bowel syndrome, and migraines. The patient was started on venlafaxine (75 mg extended-release by mouth once daily) for depression approximately 1 month prior to admission. Furthermore, the patient was restarted on a previously prescribed medication, oral phentermine/topiramate for weight loss, in combination with venlafaxine, approximately 1 week prior to the bizarre behavior. The patient denied any psychosis or changes in behavior when medications were taken individually prior to the combination. The patient was treated with lurasidone (40 mg by mouth daily) with resolution of psychosis. A PubMed search revealed no current literature or case reports on psychosis induced by the combination of venlafaxine and phentermine/topiramate. Individual case reports of psychosis in patients on venlafaxine alone and the phentermine component of phentermine/topiramate alone have been reported.Abstract
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